Emphysematous Gastritis With Portal and Mesenteric Venous Gas Complicated by Septic Shock and Ileus: A Case Report

Emphysematous gastritis (EG) is an uncommon, life-threatening cause of intramural gastric gas that may be accompanied by portal venous gas and shock. An older adult with diabetes, vascular comorbidities, and chronic constipation presented with three days of worsening generalized abdominal pain following a home-administered enema and arrived profoundly hypotensive with metabolic acidosis and elevated lactate. Non-contrast computed tomography (CT) (limited by renal dysfunction) demonstrated gas in the posterior gastric wall consistent with emphysematous gastritis, with hepatic portal venous gas (HPVG) and mesenteric venous gas, and associated ileus without pneumoperitoneum. The patient was managed conservatively in intensive care with hemodynamic support, bowel rest, nasogastric decompression, intravenous (IV) proton pump inhibitor therapy, broad-spectrum antimicrobials (with subsequent de-escalation), and parenteral nutrition, with clinical stabilization and discharge. Follow-up imaging and/or endoscopy was not completed as an inpatient due to family preference. This case highlights the need for rapid imaging and multidisciplinary risk stratification when emphysematous gastritis is suspected in shock and illustrates the potential for recovery with carefully monitored non-operative management.